sclera and episclera Constitutions in management of eye

Welcome to study Sclera and Episclera

1. DISEASES OF THE SCLERA AND EPISCLERA UNIT:OCULAR DISEASES II LECTURER:DR.KANDIE GROUP ONE PRESENTATION. PRESENTER:ANTONY W. WASWA

2. OUTLINE Introduction Episcleritis Immune mediated scleritis Infectious scleritis Staphylomas Other scleral conditions

3. Introduction Anatomy and physiology. Sclera in ‘Greek’ means ‘hard’ Is an opaque elastic and resilient tissue of connective tissue of the eye Comprises approximately 90%(five-sixths) of the outer coat of the eye Begins at the limbus anteriorly and terminates at the optic nerve canal posteriorly Primary function is to protect the eye and maintain the shape of the eye ball

4. Anatomy of sclera

5. Layers of sclera

6. Layers of sclera

7. Thickness of sclera Thinner-in children than in adults and in females than in males At the limbus-0.8mm thick Thickest-at posterior pole(1mm),gradually becomes thin when traced anteriorly Anterior to the rectus muscle insertion is 0.6mm thick Posterior to the RM insertion is 0.3mm thick(thinnest) Equator-0.5mm-0.8mm Apertures :Posterior,middle and anterior.

8. EPISCLERITIS Inflammation of the episclera,involving the overlying Tenon’s capsule but not the underlying sclera Typically affects young adults, twice in females than in men Commonest of scleral inflammation

9. Etiology Idiopathic -Not known in many cases Systemic diseases -Associated with gout,rosacea,psoriasis and connective tissue diseases Hypersensitivity reaction -to endogenous tubular or streptococcal toxins is also reported Infectious episcleritis -can be caused by herpes zoster virus,Lyme disease,syphilis and TB.

10. Pathology Histologically, occurs localized lymphocytic infiltration of episcleral tissue Edema and congestion of the overlying Tenon’s capsule and conjunctiva It is circumscribed,segmental and nodular inflammation of episclera

11. Symptoms Characterized by:Redness,mild ocular discomfortdescribed as gritty,burning or foreign body sensation Unilateral or bilateral Rarely,mild photophobia and lacrimation may occur

12. Signs On examination,two clinical types of episcleritis:Simple and nodular may be recognized a)Simple episcleritis –accounts for 75% of the cases and characterized by sectorial(Occasional diffuse) inflammation of episclera -Has great tendency to recur either in the same eye -Redness may be sectorial or diffuse -Often it has an interpapebral distribution, in contrast with disease which commonly starts in the upper temporal quadrants

13. Simple episcleritis- continuation The attack peaks within 12 hours and then gradually fades over the next few days Flits from one eye to another or may be bilateral Has localized pain

14. Simple episcleritis( sectoral )

15. Simple episcleritis(Diffuse )

16. b)Nodular episcleritis Characterized by a pink or purple flat nodule surrounded by injection,usually situated 2-3mm away from the limbus The nodule is firm,tender,can be moved separately from sclera and overlying conjunctiva also moves freely

17. Nodular episcleritis

18. Differential diagnosis Simple episcleritis may be confused rarely with conjunctivitis Nodular episcleritis may be confused with inflamed pinguecula Scleritis

19. Treatment Topical NSAIDs e.g Keterolac 0.3% Topical mild corticosteroid eye drops e.g 0.5% carboxy methyl cellulose have soothing effect Cold compress applied to the closed lids may offer symptomatic relief from ocular discomfort Systemic NSAIDs e.g flurbiprofen (300mg od)

20. SCLERITIS Is an inflammation of the sclera proper Causes visual impairment and even loss of the eye if treated inadequately Less common than episcleritis Common in elderly patients(40-70years) Affects females>males

21. Classification A.Immune-medited non- infectious,scleritis I.Anterior scleritis (98%) a).Non-necrotizing scleritis (85%) Diffuse Nodular b)Necrotizing scleritis (13%) 1.With inflammation Vaso -occlusive Granulomatous Surgically induced

22. Classification-cont.. 2.Without inflammation- Scleromalacia perforans II.Posterior scleritis (2%) B.Infectious scleritis

23. Etiology 50% cases are associated with some systemic diseases Autoimmune collagen disorders- RA,is the most common association Metabolic disorders-Gout and thyrotoxicosis Infections-Herpes zoster ophthalmicus,chronic staphylococcal and streptococcal infection Granulomatous diseases:TB,Syphilis,sarcoidosis and Leprosy Miscellaneous:Irradiation,chemical burns,Behcet’s disease and rosacea are also implicated Idiopathic in many cases of the scleritis

24. Clinical features-Symptoms Pain-Deep and boring awaking the patient Redness-localized and dffuse Photophobia Lacrimation Diminution of vision

25. Signs I.Non -necrotizing anterior diffuse scleritis - Commonest,widespread inflammation with raised and salmon pink to purple areas II.Non -necrotizing anterior nodular scleritis -One or two third,purplish elevated immovable scleral nodules

26. Non-necrotizing anterior scleritis Fig.7.3-NN anterior diffuse scleritis Fig.7.4-NN anterior nodular scleritis

27. Anterior necrotizing scleritis Fig.7.5-ANS with inflammation Fig.ANS without inflammation( scleromalacia perforens )

28. Anterior necrotizing scleritis with inflammation Intense localized inflammation associated with areas of infarction due to vasculitis The necrosed area is thinned out Sclera becomes transparent and ectatic with uveal tissue

29. Anterior necrotizing scleritis with inflammation Intense localized inflammation associated with areas of infarction due to vasculitis The necrosed area is thinned out Sclera becomes transparent and ectatic with uveal tissue

30. Anterior necrotizing scleritis without inflammation( scleromalacia perforans ) Occurs in elderly females with long-standing RA Characterized by development of yellowish patch of melting sclera This sequestration becomes dead white in color Spontaneous perforation is extremely rare

31. Posterior scleritis Inflammation involving the sclera behind the equator Frequently misdiagnosed Characterized by inflammation of adjacent structures,which include: Exudative retinal detachment, macular edema,proptosis and limitation of ocular movements

32. Treatment Non-infectious scleritis I.Non -necrotizing scleritis -Topical steroid eye drops -Systemic indomethacin 75mg twice a day until inflammation resolves II.Necrotizing scleritis -Topical steroids -Heavy doses of oral steroids then tapered slowly

33. Necrotizing scleritis Immunosuppressive agents like methotrexate or cyclophosphamide may be required in nonresponsive cases Subconjuctival steroids are contraindicated because they may lead to scleral thinning and perforation Surgical treatment,in the form of scleral patch graft may be required to preserve integrity of the globe in extensive scleral melt and thinning

34. Infectious scleritis Rare and most of the time diagnosis is delayed Initial clinical features are similar to those of immune mediated disease Infection may follow surgical or accidental trauma,endophthalmitis or extension of cornea infection Treatment -Antimicrobial therapy-both topical and oral agents are required in an aggressive manner -Surgical debridement-is found useful by debulking the infected scleral tissue and also facilitating the effect of antibiotics

35. STAPHYLOMAS Refers to localized bulging of weak and thin outer tunic of the eye ball(sclera and cornea),lined by the uveal tissue which shines through the thinned out fibrous coat TYPES -Anatomical classification:Anterior,intercalary,caliary,equatorial and posterior staphyloma a)Anterior staphyloma -An ectesia of pseudocornea (the scar formed from organized exudates and fibrous tissues covered with epithelium)which results after total sloughing off of cornea with iris plastered behind it

36. Anterior staphyloma

37. Types cont …. b)Intercalary- Localized bulge at the limbal area lined internally with the iris root and the anterior most part of the ciliary body - Resuslts due to ectesia of the weak scar tissue formed at the limbus,following healing of perforating injury or perforating corneal ulcer -Secondary angle closure glaucoma may cause the progression of staphyloma if not treated -Defective vision occurs due to marked corneal astigmatism RX -Comprise localized staphylectomy under heavy oral steroids

38. Types cont ….

39. Types cont … C) Ciliary staphyloma -Bulge of weak sclera lined by ciliary body -Occurs up to 2-3mm away from the limbus and may extend up to 8mm behind the limbus -Common causes are thinning of the sclera following perforating injury,scleritis,developmental glaucoma and endstage prmary or secondary glaucoma d) Equatoral staphyloma- due to bulge of sclera lined by the choroid at the equatorial region -Caused by scleritis and degeneration of sclera in pathological myopia and chronic uncontrolled glaucoma -Common at the regions of the sclera which are perforated by vortex veins

40. Types cont ….. e)Posterior staphyloma- Refers to bulge of the sclera behind the equator lined by the choroid -Common causes are: pathological myopia,posterior scleritis and perforating injuries -Diagnosed on ophthalmoscopy-the area is excavated with the retinal vessels dipping in it(just like a marked cupping of optic disc in glaucoma) -Its floor is focused with minus lenses in ophthalmoscope as compared with its margins

41. Types cont …

42. Types cont …

43. Types cont …

44. Other scleral conditions Porphyria Scleral discoloration- alkoptonuria,haemochrmatosis Blue sclera- Osteogenic imperfecta,Ehlers-Danlos syndrome type IV Miscellaneous conditions-congenital ocular melanocytosis,idiopathic sclerochoroidal calicification Scleral hyaline plaque and senile scleromalacia

45. THANKS Questions?.....

46. REFERENCES Kanski’s Clinical Ophthalmology 9 th Edition -Brad Bowling A.K Khurana-Comprehesive ophthalmology-7 th edition Occular anatomy and Physiology 2 nd edition AL Lens Comt and Sheila Coyne Nemeth